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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881204
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:30:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221028073905
FACILITY NAME:PITACHE RESIDENTIALFACILITY NUMBER:
361881204
ADMINISTRATOR:WILLIAMS, NATALIEFACILITY TYPE:
735
ADDRESS:18025 PITACHE ST.TELEPHONE:
(909) 671-2812
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:4CENSUS: 3DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Natalie Williams, CaregiverTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Resident medication was not administered as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with Caregiver Natalie Williams and explained the purpose of the visit. LPA requested that Williams call the Licensee because the Licensee was not present at the facility. Williams called the Licensee, and the report was discussed with the Licensee over the telephone.

The investigation consisted of a file reviews and interviews with relevant parties. The allegation alleges that on October 15, 2022, staff #1 (S1) failed to provide the medication Aspirin 325 mg to resident # 1 (R1) at the scheduled time of 4:00 p.m. LPA interview with staff #2 (S2) revealed that S2 discovered the missed dose of Aspirin 325 mg contained in the bubble pack during a medication audit on October 16, 2022. . S2 further states that they reported the missed dose of Aspirin 325 mg to the house manager on October 16, 2022. LPA interview with S3 revealed that S3 did receive a phone call from S2 reporting the missed dose of Aspirin 325 mg at 7:00 a.m. on October 16, 2022. S3 stated that because the missed dose occurred during (S1) shift, S3 called S1 and inquired about R1’s missed dose of Aspirin 325 mg. S3 further states that S1 realized they did not administer it at 5:45 p.m. but did not want to call anyone about the missed dose of Aspirin 325 mg.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20221028073905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: PITACHE RESIDENTIAL
FACILITY NUMBER: 361881204
VISIT DATE: 01/13/2023
NARRATIVE
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Based on interviews conducted, the above allegations is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conduct and copies of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20221028073905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PITACHE RESIDENTIAL
FACILITY NUMBER: 361881204
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
80075(5)(B)
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80075 Health Related Services (5)(B)

Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Licensee shall read the Title 22, Division 6, of the California Code and Regulation (CCR), Section 80075(5)(B) and submit a letter of understanding. The Licensee shall provide training on the section cited to all staff. .
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Based on interview, the Licensee did not ensure that R1’s medication is given according to the physician’s directions, which poses a potential risk to the health and safety to persons in care.
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Licensee shall submit a letter of understanding to the Regional Office (RO) with training records by the POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3